| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,032 |
1,145 |
$1.49M |
| D1120 |
Prophylaxis - child |
7,883 |
7,844 |
$564K |
| D1206 |
Topical application of fluoride varnish |
9,687 |
9,609 |
$528K |
| D0120 |
Periodic oral evaluation - established patient |
7,150 |
7,119 |
$464K |
| D1351 |
Sealant - per tooth |
6,073 |
1,679 |
$384K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,078 |
1,027 |
$361K |
| D0272 |
Bitewings - two radiographic images |
5,521 |
5,491 |
$307K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,834 |
1,003 |
$302K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,037 |
1,043 |
$259K |
| D0160 |
|
1,215 |
1,212 |
$120K |
| D0330 |
Panoramic radiographic image |
766 |
765 |
$117K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
644 |
364 |
$104K |
| D2330 |
|
618 |
323 |
$88K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,296 |
2,121 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
1,943 |
1,915 |
$72K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
669 |
$65K |
| D9420 |
|
1,008 |
1,004 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,548 |
896 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
499 |
$46K |
| D0145 |
Oral evaluation for a patient under three years of age |
304 |
304 |
$31K |
| D2331 |
|
125 |
67 |
$24K |
| D1354 |
|
836 |
521 |
$19K |
| D2934 |
|
33 |
13 |
$15K |
| D2332 |
|
31 |
18 |
$7K |
| D2940 |
|
58 |
44 |
$5K |